Shifts Ahead for Mental Diagnoses

Mental-health experts wrestling with how to fit temper tantrums, hoarding and even Internet addiction into the current understanding of mental illness are proposing changes to the field's primary reference for diagnoses for the first time in 16 years.

The draft revisions of the Diagnostic and Statistical Manual of Mental Disorders—the bible for mental health clinicians and researchers—unveiled Wednesday could have effects that ripple through mental health care.

Researchers, clinicians and insurance companies use the DSM to make diagnostic, treatment and coverage decisions. For drug companies, changes could open up opportunities for new drugs or expand the uses of existing ones. And for patients, inclusion of their disorder serves to legitimize their condition as well as potentially paving the way for new treatments.

The draft revisions, announced Wednesday, are open for public comment until April. Field trials then will be conducted to study whether the new diagnoses make sense and are useful to clinicians, including social workers, psychologists and psychiatrists. The final version, after further changes, will be published in 2013.

One new diagnosis: hoarding, where people have significant difficulty discarding personal possessions. Hoarding can lead to significant distress, and including it in the DSM is expected to increase public awareness and stimulate diagnosis and research into the disorder. Another diagnosis recommended for inclusion is "temper dysregulation disorder with dysphoria" for children with severe tantrums and irritability.

The revisions would drop Asperger's disorder, which is characterized by difficulties with social interactions and repetitive behaviors, as a separate diagnosis. It would be subsumed into a broader category of autism spectrum disorders. The draft also overhauls the family of substance-use disorders and cuts subcategories of schizophrenia.

A number of conditions proposed by international experts and consumer advocates are still being considered. These conditions include "apathy syndrome," in which people suffer from a severe lack of motivation, "seasonal affective disorder" and Internet addiction.

The latest overhaul of the manual, its fifth, isn't expected to increase the overall number of diagnoses, which is about 300. It is "trying to capture more central themes" about what defines a disorder, rather than parsing conditions into more diagnoses, said David Kupfer, chairman of the task force convened by the American Psychiatric Association to coordinate the revisions.

Deciding just what constitutes distinct mental illness has long been an issue in mental health care. "A great deal of research has gone into validating the current diagnostic system," said John Krystal, deputy chairman for research in the department of psychiatry at Yale University, who isn't involved in the task force. "But it is far from optimal."

"The greatest challenges that we face is that the patients that we group together within a single psychiatric diagnosis are quite heterogeneous," said Dr. Krystal.

A new diagnosis, "mixed anxiety depression," is proposed because many patients experience significant symptoms from both depression and anxiety. Currently, patients can be diagnosed with both disorders, but those patients haven't been studied systematically, nor has the Food and Drug Administration approved treatments specifically for them, said Darrel Regier, vice chairman of the DSM revision task force. "You can't imply that a person with major depression is going to respond in the same way if they have a significant anxiety component or if they don't."

The category of substance abuse and dependence disorders is being broadened to include nonsubstance issues, such as gambling addiction. Also, the renamed category, called "addictive behaviors," will be limited to people who go to great lengths to obtain a substance or behavior and who have extreme cravings for it.

Excluded under the changes would be people who are simply physiologically dependent, which means they need to take a higher and higher dose of a prescribed medication to get the same effect or suffer withdrawal symptoms when they stop.

With autism and Asperger's disorder, there isn't enough evidence to justify keeping current separate diagnoses, said Dr. Regier. One in 110 children is now diagnosed with autism-spectrum diagnoses, according to the Centers for Disease Control and Prevention.

The draft criteria propose that autism-spectrum disorders be viewed on a continuum of characteristics behaviors rather than distinct diagnoses.

Getting rid of Asperger's may provoke an outcry from individuals who have formed an identity and community around the diagnosis, said Dr. Regier.

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